Top 5 Insurance Questions, Plus Expert Answers

From what we hear from our members, it’s safe to say that dealing with insurance is not people’s favorite activity. A crucial piece of our work involves helping families navigate insurance and unlock funding—which we do to the tune of an average of $33,000 per family in benefits and support! During our member-only office hours we always receive a lot of questions regarding insurance. We asked Undivided Public Benefits Specialist Lisa Concoff Kronbeck and Undivided Director of Health Plan Advocacy Leslie Lobel to address 5 common insurance questions.

1. “Will Medi-Cal pay insurance co-pays and deductibles?”

Lobel notes that Medi-Cal will pay towards the deductible and co-pay, but only for the dollar amount that they allow for the specific service. “They should accept the two payments from the two sources as payment in full, regardless of whether there’s any balance after both pay. They are obligated by being contracted with both those plans to write off any balance after they receive both payments,” says Lobel. Lobel also shares that sometimes the provider will attempt to bill a family after receiving payment from both funding sources, and that families can often make that balance billing disappear by filing a grievance with Medi-Cal.

However, there is a caveat to the above. Using Applied Behavior Analysis (ABA) therapy as an example, Lobel notes that if the provider that a family has chosen is out-of-network for their primary insurance and contracted with Medi-Cal, it’s less clear who will be responsible for the deductible and the co-pay. “You definitely want to be clear and upfront with the ABA provider if they’re out-of-network for your primary but contracted with Medi-Cal so you don’t get any surprise billing from them,” shares Lobel.

2. “If my child qualifies for therapy but our choice of provider has a 6-month wait list, what do we do? My child is a Regional Center client.”

Concoff Kronbeck notes two potential options. The first is to ask Regional Center to cover the cost of the service in the interim. The second is to ask the managed care provider to contract outside of the plan with an outside provider, because if they don’t have the service, that’s functionally a denial. Concoff Kronbeck shared, “They can ask the plan to do a single case agreement temporarily with an outside provider while you’re waiting for one of their providers to open up.”

Concoff Kronbeck also notes that the length of coverage from Regional Center will depend on the wait. “Often what they’ll do is authorize for a set period of time and then revisit after that set period or when the set period of time is set to expire. They will potentially extend, depending on what insurance is reporting back,” says Concoff Kronbeck.

3. “If my insurance only covers a certain number of physical therapy sessions, can we go to Regional Center to fill the gap before the next year when insurance will pay again?”

“Regional Center should pay if you’ve exhausted all the options within your plan for a medically necessary service, and have it in writing that no more benefits are available for the year,” shares Lobel. However, Lobel notes that it’s important for families to understand that Regional Center will likely not cover if services are denied by the health plan for some other reason besides maxing out the benefit (e.g., if your claim shows that you’ve made an error in submission, if the claim was denied for lack of medical necessity, if the claim was filed late).

In the case of physical therapy, Concoff Kronbeck also points out the importance of age. “Once a child turns three, Regional Center will say that the school district has responsibility for providing physical therapy, but this same answer would apply, for example, with durable medical equipment or incontinence supplies. It has to be something that’s within the scope of what the Regional Center is responsible for given the child’s age.”

4. “Is there a benefit to dropping private insurance and relying solely on Medi-Cal?”

Concoff Kronbeck advises that in some cases there may be rules against this tactic given that Medi-Cal wants people to use private insurance first. For example, if an employer provides insurance at no cost, you likely need to retain that insurance.

That said, Concoff Kronbeck notes that there are scenarios where people have opted to drop private insurance and rely on Medi-Cal; for example, if they are already paying a large amount out-of-pocket for private insurance. “If you’re in a situation where you’re paying out-of-pocket for private insurance and you’re considering dropping it, think through your child’s needs. It depends on what your private plan covers versus what Medi-Cal covers,” notes Concoff Kronbeck.

5. “If we’re changing insurance and want to retain the same provider, should we request continuity of care?”

According to Lobel, continuity of care is a short-term exception that allows you to stay with your provider for a limited period of time while you transition to a new network provider. You are, in effect, agreeing at some point to transfer service providers with the new plan.

“What you may want to consider doing instead is request to remain with your current provider by proving, if you can, that there’s no one in the new plan—in the present or the future—who is able to appropriately serve your child,” advises Lobel. Lobel urges families not to make requests based on reasons such as being with the current provider for a long time, or that you prefer the provider. Instead, families need to communicate that there are no other medically appropriate or safe options. Lobel notes that this is called an access-to-care exception and is what health plans are actually contractually obligated to provide. The ability to prove access-to-care varies, but it can be a longer-term solution with some plans than continuity of care. Instead of agreeing that eventually you’re going to transfer to a new network provider, you’re making a bigger case for your current provider’s necessity.

Concoff Kronbeck underscores the importance of advocating based on a medical necessity vs. a preference. She shares this common example: “If a child is working with a therapist and that therapist is a specialist in oral motor or swallowing, and they have licensure training specific to that, that speech therapist or occupational therapist is trained to keep that child safe and not choking or aspirating while they’re working on developing that swallow,” shares Concoff Kronbeck. In a scenario like this, Concoff Kronbeck also advises asking a doctor to write supporting documentation to indicate medical necessity.

For more information and to dig into additional funding options, check out our popular guide, How Do We Pay For It All? Undivided’s Guide to Funding Resources. And consider an Undivided membership so you can get your burning questions answered during our member office hours.